Aveiro 2019
ANA FILIPA TAVARES PEREIRA
INTERVENÇÃO PSICOLÓGICA EM CRISE VIA TELEFONE
PSYCHOLOGICAL INTERVENTION IN CRISIS BY TELEPHONE
Aveiro 2019
ANA FILIPA TAVARES PEREIRA
INTERVENÇÃO PSICOLÓGICA EM CRISE VIA TELEFONE
PSYCHOLOGICAL INTERVENTION IN CRISIS BY TELEPHONE
Dissertação apresentada à Universidade de Aveiro para cumprimento dos requisitos necessários à obtenção do grau de Mestre em Psicologia da Saúde e Reabilitação Neuropsicológica, realizada sob a orientação científica do Prof. Doutor José Martin, Professor Auxiliar do Departamento de Educação e Psicologia da Universidade de Aveiro
Dedico este trabalho à minha família, pelo seu incontornável apoio e
especialmente ao meu pequeno D. pela sua capacidade de transformar os dias mais cinzentos em dias luminosos, com o seu sorriso.
o júri
presidente Professora Doutora Anabela Maria Sousa Pereira
Professora Associada com Agregação do Departamento de Educação e Psicologia da Universidade de Aveiro
Professora Doutora Maria Madalena Jesus Cunha Nunes
Professora Adjunta da Escola Superior de Saúde do Instituto Politécnico de Viseu
Professor Doutor Jose Ignacio Guinaldo Martin
agradecimentos A utilização neste documento dos verbos na primeira pessoa do plural existirá não apenas por uma questão de adequação, mas também por tanta
contribuição e herança deixada por outros profissionais, autores e pessoas comuns com quem me cruzei e que tanto ou mais me deram (mais do que acredito terem recebido de mim). É mais do que justa a utilização do “Nós”. Assim, agradeço:
- Em primeiro lugar aos meus orientadores, ao Professor Jose Ignacio Martin, pelos momentos de partilha, apoio e motivação contínua, por acreditar no estudo. À Dra. Sara Rosado co-orientadora designada pelo INEM, pela disponibilidade, transmissão de conhecimentos e pragmatismo, pelo seu contágio positivo.
- Ao Instituto Nacional de Emergência Médica (INEM), pela possibilidade de acesso a tão rica fonte de informação.
- A todos os elementos do Centro de Apoio Psicológico e de Intervenção em Crise (CAPIC), que sem saberem, juntamente com as vítimas, ao longo destes anos foram (e são) a base deste trabalho. Grata por todos os contributos e crescimento neste percurso, procurarei retratar com a maior dignidade este serviço de excelência em Portugal.
- A todos os que participaram em tarefas específicas ao longo da investigação, nomeadamente ao Sr. Sousa do Departamento de Informática do INEM, pela sua incansável resposta e disponibilidade e, especialmente, ao Dr. Domingos Silva a quem dirijo uma palavra de apreço pelo seu imprescindível apoio no tratamento estatístico dos dados.
- Por último, mas não menos importante, agradeço à minha família e amigos, minha incontornável rede, por todo o apoio e fé depositada...
Obrigada!
palavras-chave Crise, Intervenção em Crise via telefone, Chamadas de Emergência, Central de Emergência Médica
resumo Em Portugal, a intervenção psicológica em crise e emergência, via telefone, é assegurada num contexto pré-hospitalar, por psicólogos do Centro de Apoio Psicológico e de Intervenção em Crise (CAPIC).
Este estudo pretende demonstrar a intervenção dos psicólogos do CAPIC no Centro de Orientação de Doentes Urgentes (CODU) através da análise dos dados registados no Software CAPIC, de 2013 a 2018, num total de 50226 situações.
Através de uma Análise de Correspondência Múltipla (ACM), pretendemos identificar possíveis perfis no espaço definido por um conjunto de variáveis categóricas ligadas aos sinais e sintomas, bem como ao tipo de ocorrência, género e intervenção do psicólogo através da referenciação, procurando investigar as múltiplas relações que é possível estabelecer entre elas num contexto de interdependência.
Foi possível identificar duas dimensões: a dimensão 1, composta por indicadores de "sintomatologia" e a dimensão 2, que aponta essencialmente para "características do evento", demonstrando uma partilha intencional comum entre as variáveis. Foi a sintomatologia que pareceu ter maior contributo na explicação dos dados.
Pelo seu caráter único e inovador, pode-se considerar este estudo pioneiro, contribuindo para o conhecimento do papel do psicólogo na Central de Emergência Médica, pelo que se avança a necessidade de mais investigação que possa aprofundar esta temática, uma vez que a nível mundial não é conhecida realidade similar. Algumas limitações prendem-se com as
caraterísticas da aplicação informática utilizada que pode levar a alguns dados menos objetivos. Sugere-se ainda a introdução de outras variáveis em estudo por forma a avaliar o sucesso da intervenção.
keywords Crisis, Crisis Intervention by Telephone, Emergency Calls, Emergency Medical Center
Abstract In Portugal, the psychological intervention in crisis and emergencies, by telephone, is ensured in a pre-hospital setting by psychologists from the Center for Psychological Support and Crisis Intervention (CAPIC).
This study endeavors to demonstrate the intervention of CAPIC´s psychologists in the Dispatch and Guidance Center for Urgent Patients (CODU) through the analysis of data registered in CAPIC Software from 2013 to 2018 in overall 50226 situations recorded.
Through a Multiple Correspondence Analysis (MCA), we pretended to identify possible profiles in the space defined by a set of categorical variables
associated to the symptoms as well as the type of occurrence, gender, and the intervention of the psychologist through referral, in an effort to investigate the multiple relationships that are possible to establish between them in the context of interdependence.
It was possible to identify two dimensions, namely dimension 1, composed of indicators of “symptomatology” and dimension 2 that essentially points to “characteristics of the event”, demonstrating a common intentional sharing between the variables. However, it was the symptomatology that seems to have the greatest contribution in explaining the data.
Owing to its unique and innovative character, this study can be considered a pioneer, contributing to the knowledge of the role of the psychologist in the Emergency Medical Center. Therefore, there is a need for more research that can deepen this theme, since worldwide no similar reality is known. Some limitations relate to the characteristics of the computer software used, which may lead to less objective data. In order to evaluate the success of the intervention, the introduction of other variables is suggested.
Table of Contents Introduction ...1 Method ...3 Sample ...3 Material ...4 Procedure ...4 Results ...5 Discussion ...13 References ...18 APPENDIX ...22
List of Tables
Table 1 –Frequency of responses in variables “type of caller”, “gender”, and “age” ...3 Table 2 – Absolute and relative frequency of responses in the classes of the “occurence type” and “subtype”. ...7 Table 3 – Absolute and relative frequency of responses in the classes of the variables “psychological intervention”, “referral”, and “dispatch proposal by psychologist” ...7 Table 4 – Absolute and relative frequency of responses in the classes of the variables “cognitive, behavioral, physiological, and emotional signs and symptoms” ...8 Table 5 – MCA dimensions: a-Cronbach, Eigenvalue, inertia, % inertia, and % of variance ...9 Table 6 – MCA dimensions discrimination measures ...10 Table 7 – Crosstabulation between “occurence type” and “gender” ...13
List of Figures
Figure 1 – Configuration of the space of the variables under study: plan 1*2 ...10 Figure 2 – Join Plot of category points ...11 Figure 3 – Dimensions discrimination features ...12
List of Abbreviations
CAPIC – Center for Psychological Support and Crisis Intervention CODU – Dispatch and Guidance Center for Urgent Patients EMS – Emergency Medical Services
IBM SPSS ® – Statistical Package for the Social Sciences INEM – National Institute of Medical Emergency
MCA – Multiple Correspondence Analisys MEM – Medical Emergency Motorcycle NGO – Non-governmental association
SIADEM – Integrated medical emergency assistance and dispatch system SIV – Immediate Life Support Ambulance
SNS – National Health Care Service
TEPH – Pre-Hospital Emergency Technicians
TETRICOSY ® - Telephonic Triage and Counseling System UMIPE – Mobile Unit for Psychological Emergency Intervention UN – United Nations
VIC – Catastrophe Intervention Vehicle
Introduction
Since beginning of times, man has sought of providing health care to victims of all kinds in emergencies. The records of a medical emergency system dates back to the great wars in Europe (Mateus, 2007). Bearing in mind various factors and situations, the attempts to provide health care in the area of pre-hospital medical emergency began to emerge (Cunha, 2018).
In Portugal, pre-hospital assistances to patients began in 1965 (Cunha, 2018). The medical emergency line 112 (single European emergency telephone number) was activated. The National Institute of Medical Emergency (INEM, I.P.) is a government administrated company responsable for EMS (Emergency Medical Services). The Dispatch and Guidance Center for Urgent Patients (CODU) is ensured by Doctors, Psychologists and Pre-Hospital Emergency Technicians (TEPH). These profissionals receive the emergency calls and provide care, triage, and pre-help counselling and dispatch the most appropriate pre-hospital resources. The CODU decides the best response for different patients, including hospital needs, through direct communication and preparation for their arrival (Law Decree nº 14041/2012).
The support of computer equipment is fundamental. It is used as an integrated medical emergency assistance and dispatch system (SIADEM) that includes, since 2012, a Telephonic Triage and Counseling System - TETRICOSY®, a medical priority system with decision support in algorithms (Cunha, 2018). All the psychological emergency calls are transferred by the TEPH to the psychologist following the proposed response of the triage algorithm. Whenever a professional identifies the need to report an event to the psychologist, there is an intervention directly with the caller (Cunha, 2018).
A local emergency response is sent with an ambulance or a Medical Emergency Motorcycle (MEM) for lower priority situations. For complex situations, a VMER (Emergency and Resuscitation Medical Vehicle) or a Medical Helicopter (both crews carry a doctor and a nurse) can be dispatched. Since 2007, the Ambulance SIV (Immediate Life Support Ambulance) (with a nurse and a TEPH) is being sent for complex situations. Specifically, in multi-victim situations, the Catastrophe Intervention Vehicle (VIC) is used. However, in critical events with traumatic potential such as unexpected or violent deaths, psychiatric emergencies, interpersonal violence or sexual abuse, exception/multivictim situations or serious situations involving children, the Mobile Unit for Psychological Emergency Intervention (UMIPE), managed by a psychologist and a TEPH (INEM, 2017a; INEM, 2017b), can be activated.
The attendances made by psychologists are registered with details in a computer specific software named CAPIC, the acronym of Center for Psychological Support and Crisis Intervention.
The psychologist also provides support and advice to the teams in the field with CODU’s professionals. He can also assist in the management of difficult and/or problematic calls. This service is provided 24 hours a day by a team of clinical psychologists with specific training in psychological crisis intervention, psychological emergencies, and psychosocial intervention in catastrophe (INEM, 2017a; Portuguese Ministerial Ordinance nº 458-A/2004 – Internal Rules of the INEM).
New forms of psychological intervention are possible thanks to technological advancements, improving health care responses and popularity growth of "telehealth" or "teleassistance" (Jerome et al., 2000). The telephone is currently the most prevailing form of initial contact in most crisis interventions, and there are several reasons behind its successful use, which include anonymity, less dependence on a specific professional, accessibility and immediacy, and allowing individuals to have 24-hour help (Gross & Anthony, 2003).
Moreover, the telephone has been widely used for various purposes by mental health professionals, particularly in situations of psychological intervention in crisis. A significant proportion of calls involves individuals in psychological crisis or in emergency situations (Schnelle, Gendrich, McNees, Hanna & Thomas, 1979; Grigg, Herrman, Harvey & Endacott, 2007). The goals are ensuring safety, preventing harm, and promoting recovery (Kahn, 2001; Flannery & Everly, 2000).
A psychological emergency is characterized by a serious disorder of thought, feeling, behavior, and perception resulting from a mental illness or an event itself causing inappropriate behaviour and associated risk (Chaput, Paradis, Beaulieu & Labonte, 2008; Hillard and Zitek, 2004). Therefor, it is potentially fatal and necessitates a quick assessment and intervention (Glick, Berlin, Fishkind & Zeller, 2008). Most psychological disorders are associated with crisis during the acute phase, which can rapidly evolve into an emergency situation without rapid intervention (Roberts, 2005). The emergency situations resulting from affective disorders (like depression with suicidal behaviour) and psychotic crisis (Allen, 2000) are common, like intoxications (Latt et al., 2011), panic attacks (Merritt, 2000) and acute psychopathologies in individuals with antisocial and borderline personality disorders (Knott & Isbister, 2002). In other cases, individuals with no psychopathological history may present themselves in the context of a first episode of psychotic crisis or drug-induced psychosis (Ali et al., 2010), after potentially traumatic situations (Morrison, Frame & Larkin, 2003) like the exposure to accidents (IASC, 2007). The elderly also seems to be vulnerable to emergency situations, especially in acute dementia, wherein cognition is severely impaired, as well as the cases of severe depression and co-morbid conditions (Walsh, Currier, Shah, Lyness & Friedman, 2009). The management of psychological crisis and emergencies has received increasing attention in recent decades (Lomeña, 2007; Sá, Werlang & Paranhos, 2008; Allen, Carpenter, Sheets, Miccio & Ross, 2003). However, the integration of the psychologist in a pre-hospital medical emergency and
dispatch center seems to be a unique reality in Portugal. The lack of existing scientific evidence on the recommended practice by telephone to this type of reality makes its comparison more reductive. This study tries to demonstrate the intervention of CAPIC´s psychologists in the CODU, which applies to people assisted by clinical conditions, accidents or violence, unexpected deaths of family members or friends as well as the families and community involved in addition to the health professionals involved in the occurrences. Through a Multiple Correspondence Analysis (MCA), we pretended to identify possible profiles in the space defined by a set of categorical variables linked to the symptoms as well as the type of occurrence, gender, and the intervention of the psychologist through referral, seeking to investigate the multiple possible relationships in the context of interdependence.
Method Sample
Participants (n = 50226) were callers who received psychological assistance, from 2013 to 2018, in the Portuguese medical emergency center, mostly females (n= 31424 or 62,6%) although the gender is not mentioned in 4,3% cases. The range age was 0-103 years (M=41,4, SD= 7,99 years).
According to the United Nations age stratification (UN, 2009), the most frequent age groups were adults, namely "19-25 years" (10,9%), "26-44 years" (32%) and "45-59 years" (25,2%), representing a total of 68,1% of the sample.
Regarding the type of caller, in most cases, it is the "patiet himself" (44,1%) who makes the call, followed by a "family member" (28,1%) or a "known person" (6,8%) (Table 1).
Table 1 –Frequency of responses in variables “type of caller”, “gender”, and “age”
n % n %
Type of caller Age
Patient himself 22149 44,1 0-2 34 0,1 Family member 14111 28,1 3-6 138 0,3 Known person 3420 6,8 7-10 384 0,8 INEM’s Professionals 2358 4,7 11-18 4629 9,2 Friend/Partner 2314 4,6 19-25 5459 10,9 Police 1822 3,6 26-44 16055 32,0 Ambulance Crew 1260 2,5 45-59 12635 25,2 Health Professional 766 1,5 60-64 2050 4,1 Social Worker 228 0,5 65-90 4926 9,8 Other 1798 3,6 +90 152 0,3 Gender No answer 3757 7,5 Female 31424 62,6 Male 16643 33,1 Unidentified 2164 4,3
Material
Software CAPIC (INEM, 2009) was used to collect data, obtained according to the information accessible to the psychologist at the time of the emergency call. It was registered during the call, or as soon as possible, using the computer application that stores all the information and allows its use online or in back office mode. In the study, the used variables include “gender”, “age”, “type of caller” (Table 1), “occurrence type” and “subtype” (Table 2), “psychological intervention”, “referral” and “dispatch proposal by psychologist” (Table 3), and “cognitive, physiological, behavioral and emotional signs and symptoms” (Table 4).
Procedure
The SPSS package v23 (IBM SPSS ®) was used to conduct all statistical analysis (IBM, 2015). Data analysis was structured as follows. The exploratory data analysis focused on the absolute frequency (n) and relative frequency (%) for qualitative variables. A Multiple Correspondence Analysis (MCA) was also carried out to explore associations between the variables in order to build a space where different profiles of candidates are formed. MCA is a multivariate statistical technique for exploratory analysis of categorized (or nominal) data, with the objective of extracting a greater number of information from the variables taking into account their interrelations. The MCA seeks to find and represent the relationships between variables in a multidimensional space, distributing individuals by the relevant dimensions for the observation of their differences. In other words, it extracts relationships between categories and defines similarities or dissimilarities between them. If there are similarities, it will allow their grouping. In this study, we used the variables such as “gender”, “type of occurrence”, “referral”, “cognitive signs and symptoms”, “behavioral signs and symptoms”, and “physiological signs and symptoms”. The variables such as “psychological intervention”, “proposal dispatch by psychologist”, and “emotional signs and symptoms” owing to multiple responses were not included. The MCA was made by following these steps: (1) the maximum possible number of dimensions and respective own values were determined, (2) according to the eingenvalue of each dimension, its impact on both inertia and the percentage of variance explained was verified, and decision was made about the number of dimensions to be retained, (3) for each dimension retained, the measures of discrimination of the variables introduced in the model were obtained, (4) graphical method was used to observe which dimension best represents the categories of the variables under study, (5) the method of normalization "variable principal” in the construction of the graph of measures of discrimination was used, (6) the set of all categories
combined in a single graph, observing the dimension that best discriminates them was observed, and (7) the values of mass, inertia, quantification and contribution of the categories were obtained (Carvalho, 2008; Hoffman & de Leeuw, 1992). To describe the relationship between “occurence type” and “gender” variables, a contingency table (crosstab) was made, especially to determine the number of times a particular combination of the categories occured (Marôco, 20111). We also aimed to verify the existence of independent relationships between two qualitative variables (referral and symptomatology i.e. the cognitive, behavioral and physiological signs and symptoms), using Pearson's chi-square independence test (c2). This test assumes that no cell in the table has an expected frequency of less than 1 and no more than 20% of the cells have an expected frequency of less than 5 units. In the impossibility of fulfilling the assumptions, we used the Monte Carlo simulation, using 10,000 samples, with a significance level of 1%. The hypotheses under study are (1) H0: there is no relationship between the variables, therefore they are independent of each other; (2) H1: there is a relationship between the variables, therefore, they relate to each other (Marôco, 2011).
The study was approved by INEM, I.P.
Results
The most frequent types of occurrence were "behavioral/emotional change" (55,1%), "suicidal behaviors" (30,2%), and "incident" (9%). In the remaining cases, the frequency of types of occurrence is less than 5%, with lower frequencies, i.e. <1%, recorded in "homicidal behaviors", and “interpersonal violence”. In turn, the subtypes of occurrence most commonly reported were "acute psychopathology" (17,6%), "anxiety attack" (16%), and "suicide ideation" (14,4%). Residual frequencies, although not neglectable, are considered in the categories of "domestic accident", "attempted murder", "work accident", "fire", "robbery/stealing", "homicide intent", "economic deprivation", "homicide ideation", "road accident", "neglet of the dependents", "psychological abuse", and "physical abuse" (Table 2).
In terms of psychological intervention, in most cases, more than one type was performed. Therefore, in total, 130590 actions were made. The most frequent was "counselling" (41,1%), followed by "event management support" (27,8%), "emotional stabilisation" (16,6%), and "psychoeducation" (5,8%). Less frequent, but not neglectable, actions are "early grief support, "death notification counselling", "negotiation in situations of imminent risk of suicide", and "activation of the social support" (Table 3).
by psychologist", are also highlighted. Most subjects did not require immediate referral (76,8%). Among those who were referenced, the highest rate was found for the "psychiatrist" (13,3%), followed by the "primary health care doctor" (5,5%). The proposal dispatch made by psycologists, with the approval of regulator doctor, shows that in most cases, more than one vehicle has been used. For this reason, in total, 21590 proposed dispatches were carried out. Of the total number of calls, in 54451 calls, there was no need to use pre-hospital emergency vehicle (71,6%). However, whenever it was necessary, the "ambulance" was the most used (19%), followed by "police" (5,7%), an element of the portuguese integrated medical emergency system (Table 3).
Regarding symptomatology, the most common cognitive symptoms included "suicide ideation" (30,5%), "suicide intention" (18,1%), and "incoherent speech" (6,5%). The emotional signs and symptoms allowed the choice of multiple responses, so the total number of responses was 83569. The highest frequencies were found in "anxiety" (26,9%), "emotional dysregulation" (16%), "depressive mood" (15,2%), "sadness" (7,8%), "angst" (6,7%), and "despair" (6%). At the behavioral level, "uncooperative" (22,3%), "aggressiveness/violence" (17%), "compulsive crying" (12,9%), "psychomotor agitation" (11,5%), "addictive behavior" (8%) and "disquiet" (6,9%) stood out. Physiologically, the most frequent signals and symptoms were "hyperventilation" (14%), “tremor" (10,2%), "paresthesia" (7,3%), and "intoxication" (6,8%). However, there were none physiological, cognitive and behavioral signs and symptoms in 30,4%, 13,8% and 8,9% cases respectively (Table 5). Note that it is difficult to collect information at moments of such intense emotional burden and expression. In addition, the fact that caller and patients are not always the same person makes the access to the information difficult.
of the “occurence type”, and “subtype”. of the variables “psychological intervention”, “referral”, and “dispatch proposal by psychologist”.
emotional signs and symptoms”.
Multiple Correspondence Analysis
From the MCA analysis, a two-dimension MCA solution was considered the most adequate. Only the variables "gender" and "type of occurrence" showed the presence of missing data. All the variables are active, i.e. they were all used to characterize the charts of values and representations of the MCA. The quality of the variables was assessed after reading the discrimination measures, and several tests were conducted to assess the discriminatory capacity of the variables that were chosen in each trial until we found a solution; not only the variables that best explained the total variance were present, but also those that ensured greater diversity in the characterisation of the analysis space.
The first step was to determine the maximum number of dimensions (Dmax). It was obtained by r-g, where r is the number of active categories and g is the number of variables without missings (Carvalho, 2008). In this study, as the number of subjects (n=50226) is higher than the number of categories (r=88), then Dmax =r-g=88-6=82 dimensions. However, we can also use the Eigenvalues and Inertia indicators (I). Since it is exaggerated to build a model with 86 dimensions, it is known that the most reasonable thing is to find the final solution between two or three dimensions. Thus, our first model focused on three dimensions. However, given the increase in distance from the second dimension, in addition to the increase in explained variance tending to be minimal, we chose to carry out a study focusing on two dimensions. Regardless of the number of dimensions to be retained, this does not change the solution found for the quantifications (Gifi, 1990).
Table 5 shows the structural and significant properties of the two retained dimensions, namely information on a-Cronbach, the own value, the inertia, and the % of variance explained for the two retained dimensions. The a-Cronbach (calculated based on the active variables after transformations, used for the purpose of the optimal quantifications), allowed evaluating the model's adjustment quality, dimension-by-dimension, presenting a high value for dimension 1 and, a relatively low value for dimension 2, i.e. D1: ac=0,704 e D2: ac=0,165 (Table 5).
Table 5 – MCA dimensions: a-Cronbach, Eigenvalue, inertia, % inertia, and % of variance Dimension a-Cronbach Eigenvalue Inertia % Inertia % Var
1 0,704 2,421 0,4035 40,35 2,93
2 0,165 1,160 0,1933 19,33 1,40
Total 3,581 0,5968
Discrimination measures were obtained. Clear differenting values were allocated to each of the obtain dimensions. The most discriminant variables for dimension 1 hierarchiacally were “cognitive signs and symptoms”, “behavioral signs and symptoms”, “physiological signs and symptoms”, and “referral”. Regarding dimension 2, the most discriminant variables were “occurence type” and “gender” (Table 6).
Table 6 – MCA dimensions discrimination measures Dimension 1 2 Mean Gender 0,001 0,517* 0,259 Occorrence type 0,026 0,548* 0,287 Referral 0,217* 0,009 0,113 Cognitive SS 0,815* 0,023 0,419 Behavioral SS 0,707* 0,032 0,370 Physiological SS 0,655* 0,030 0,342 Active Total 2,421 1,160 --- Inertia 0,4035 0,1933 ---
From the results, dimension 1 was termed as “Symptomatology”, and dimension 2 was termed as “Characteristics of the event”. Figure 1 provides an additional tool for the interpretation of the dimensions, this time considering the variables. In this study, the discrimination measures were obtained by the normalization method based on the option variable principal. In this figure, referring to plan 1*2, it is observed that no variable discriminates simultaneously in both dimensions, because the projections do not ensue in a diagonal line.
Figure 2 gathers all the categories of variables in a common space (joint plot of category points). It is visible by the colored spot that most categories have discrimination in the range (-0.6; 1.0), regardless of the dimension. The most distant categories belong to the variables "occurence type" (homicidal behaviors; interpersonal violence), "cognitive signs and symptoms" (depersonalisation), and "behavioral signs and symptoms" (bruxism).
Figure 2 – Join Plot of category points
Regarding the quantifications, regardless of whether the sign is negative (-) or positive (+), this has no implications for the interpretation of the results, since it is important that the coordinate moves away from zero in order to have greater differentiation on the objects under study. Owing to the high number of categories under analysis, in order to facilitate the reading of the results, we made figure 3, the dimension discrimination features.
Hetero risk injury Hetero risk injury (b) Self risk injury (1) Cognitive symptoms (2) Behavioral symptoms (3) Physiological symptoms (4) Referral Dimension 1 < 0 (1) Attention shifting, increase/decrease in consciousness, confusion, delusions, disorientation, speech difficulty, difficulty in focusing attention, incoherent speech, cognitive distortions, homicide ideation, suicide ideation, intrusions, suicide intention, denial, obssessive thougts, disturbing thoughts, another; (2) Psychomotor agitation, aggressiveness/violence, antisocial, self-mutilation, compulsive crying, additive behaviour, negativism, parakinesia, uncooperative, sleep deprivation; (3) All psysiological signs and symptoms except xerostomy and adventytious visual impairment; (4) Social worker, Primary health doctor, Psychologist, Psyquiatrist, another. Dimension 1 > 0 (1) Unregistered Cognitive SS; (2) Unregistered Beavioral SS; (3) Unregistered Physiological SS; (4) Without referral. (1) Occurrence type (2) Gender Dimension 2 < 0 (1) Behavioral/Emotional change, Interpersonal violence; (2) Female. Dimension 2 > 0 (1) Homicidal behaviors, suicidal behaviors, social situation; (2) Male. Dimension 2 Dimension 1 Without referral With referral (a)
Figure 3 – Dimensions discrimination features:
Cross Tabulation between Occurence Type and Gender
What stands out most is the large frequency of female in behavioral/emocional change (38%), suicidal behaviors (17,7%), incident (5,2%), social situations (0,3%), and interpersonal violence (4,1%). Males only highlight in homicidal behaviors (0,3%) (Table 7).
Table 7 – Cross tabulation between “occurence type” and “gender”
Gender Total Female Male Occurence type Behavioral/Emotional Change Count 18247 8504 26751 % of Total 38,0% 17,7% 55,7%
Homicidal behaviors Count 64 158 222
% of Total 0,1% 0,3% 0,5%
Suicidal behaviors Count 8485 6108 14593
% of Total 17,7% 12,7% 30,4%
Incident Count 2506 1462 3968
% of Total 5,2% 3,0% 8,3%
Social situation Count 160 115 275
% of Total 0,3% 0,2% 0,6%
Interpersonal violence Count 1958 294 2252
% of Total 4,1% 0,6% 4,7% Total Count 31420 16641 48061 % within occurence type 65,4% 34,6% 100,0%
Independence chi-square test
At a significance level of 5%, the independence chi-square test showed that there is statistically significant evidence to reject the null hypothesis of independence ((c2=2730,246; p<0,0001), p<0,0001), so the variables “referral” and “cognitive signs and symptoms” are related. Also, there is statistically significant evidence to reject the null hypothesis of independence (c2=1620,772; p<0,0001), so the variables “referral” and “behavioral signs and symptoms” are also related. Plus, there is statistically significant evidence to reject the null hypothesis of independence (c2=1620,772; p<0,00011), so the variables “referral” and “physiological signs and symptoms” are associated.
Discussion
In many developed countries, the mental health care services, supplied by phone, offer a continuous support (24h/day, 7 days/week) through a large variety of specialized
interventions, such as assessment, counselling, support, early stages intervention, and hospital unit forwarding (Barnet et al., 2009; Sands, 2009).
In Portugal, the psychological crisis intervention through phone is included in the emergency pre-hospital care approach, by calling 112 and connecting to the Medical Emergency Center, where psychologists from CAPIC are working and addressing all matters. This might be the only emergency unit in the world having such mental health professionals.
Therefor, in 2009, another portuguese study presented data from the first 9 months of CAPIC in CODU (Oliveira et al., 2009), and now we are presenting the results for the last 5 years of assistance.
Our results demonstrate that the most answered emergency calls are made by adult women, and the crisis intervention is with themselves or with a family member who is calling for them. Most readings about this issue show that family and/or other members involved are part of the process because they can predict and detect a crisis, but sometimes they are unable to deal it directly, so they need help and support (Sands et al., 2013).
A large proportion of the calls involved emotional/behavioral changes, such as “acute psychopathology”, “anxiety attack”, and “aggressiveness” episodes, followed by “suicidal behaviors”, these being the most frequent typologies. It may be understood that most answered calls are related to psychological/psychiatric crisis, which may result in a risk of injury to the patient itself or others (Oliveira et al., 2009; Sands et al., 2013).
Regarding the symptoms presented, the the most frequent were “suicide ideation” (30,5%), “suicide intention” (18,1%), “anxiety” (26,9%), “uncooperative” behavior (22,3%), “aggressiveness/violence” (17%), “emocional dysregulation” (16%), “depressed mood” (15,2%), “hyperventilation” (14%), “compulsive crying” (12,9%), “psychomotor agitation” (11,5%) “tremor” (10,2%), “addictive behaviors” (8%), “sadness” (7,8%), “paresthesia” (7,3%),“intoxication” (6,8%), “angst” (6,7%), “incoherent speech” (6,5%), and “despair” (6%). They were consistent with the already written literature about symptomology associated with psychological crisis (Ehrenreich & McQuaide, 2001; Leon, 2004; Ruzek et al., 2004; Young et al., 2001; Bacharach et al., 2008; Noy, 2004; DeWolf, 2000).
Regarding psychological intervention, CAPIC’s psychologists consistently confirm the need to immediately stabilize, responding to the presented needs, considering “counseling” in the psychological approach, followed by “occurrence support management” and “emotional stabilization”, the most frequent intervention being done. Generally, the psychological counselling aims at making the individual able to have a better understanding of himself, others, and the situation itself, helping him in taking positive decisions (Rowland, 1992). This
is the mostly used help technique visible in psychologic crisis interventions by phone, seen in the majority of the studies (Sands, et al., 2013; Oliveira et al., 2009). Nevertheless, the “occurrence support management” also stands out (with 27% of the cases), if compared with the 9,9% that resulted from the other portuguese study (Oliveira et al., 2009). This percentage growth is owing to the increase in experience over the years by the psychologists themselves and a higher professional awareness for this type of intervention and support.
Individuals in moments of crisis are more vulnerable and therefor will, more likely, accept the help, which makes it fundamental that this support is immediately available, decreasing the negative impact of situations, making the development of active adaption strategies possible (Oliveira et al., 2009). Thus, there is a need to have a psychologist available on the CODU, which also contributed to some savings. It can be seen in this study that CAPIC’s psychologists deal with psychological emergencies by phone, and in only 19% of the cases, a medical emergency ambulance was needed, because they are trained to assess, manage, and respond to a crisis. The evolution is positively clear compared with the moment when CAPIC was included on CODU, where the percentage of cases that required the medical emergency ambulance was 29% (Oliveira et al., 2009).
Not only this service proved to be essential in crisis situations, giving access and maintenance of mental health care as well as CAPIC’s psychologists can be a source of communication on matters of primary and secondary health services. Although most individuals didn’t need referral to an immediate psychologist, those who needed that intervention (23,2%) were sent to the psychiatrist as well as the primary health doctor. Bearing in mind the existent information in Portugal, this last one is an important key to the referral to mental health service aid (Lopes et al., 2017; Sarmento, 1997).
The chi-square test allowed demonstrating a clear association of cognitive, physiological, and behavioral signs and symptoms with referral, which may show the need of this kind of psychologist approach in suicidal behavior (30,5% of the individuals with “suicide ideation” and 18,11% with “suicide intention” were referral), physiological alteration situation (“hyperventilation”, 14%, “tremor”, 10,2%), and behavioral alterations (“uncollaborative”, 23%, “aggressiveness/violence”, 17%, and “compulsive crying”, 12,9%), especially for individuals with prior psychiatric care.
We must emphasize that the large majority of the cases which were oriented towards the emergency services are presumed to a posterior referral from the hospital units to the mental health services, justifying the absence of need to refer them to pre-hospital care. This can increase the eficiency of the health resources through the coordination between the
professionals and also help manage the interface with other specialties (Jordão, 1995), which reveals the great service quality supplied by our National Health Care Service (SNS) (Araújo et al., 2015).
Unprecedentedly, we analysed, through MCA, multiple relationships that are possible to be established between the variables in the context of interdependence and found the psychologist's role in intervention by referral. This technique allows the analysis of the relations between variables and different categories/levels of each variable, offering at the same time, as compared to other methods, statistical results that can be seen both analytically and visually.
The percentual map (Figure 2) shows that there is the proximity of the variables; the common intentional share of these variables is the most important one. From the results, dimension 1 was termed as “Symptomatology”, and dimension 2 was termed as “Characteristics of the event”.
It seems that in dimension 1, the referred individuals were the ones, who presented more cognitive, behavioral, and physiological signs and symptoms, representing a higher level of instability. Therefor they need continuous support and metal health services maintenance (Sands, Elsom & Gerdtz, 2010; Figure 3).
Regarding the characteristics of the event, it seems that in dimension 2, the highest levels of positive and negative centroid place the situations with high risk injury for others (homicidal behaviors and interpersonal violence), and in the middle of centroid, we found the self injury risk (behavioral/emotional changes, suicidal behaviors). Notice that the most distant categories belong to the variables "occurence type" (homicidal behaviors (0,5%), interpersonal violence (4,7%), "cognitive signs and symptoms" (depersonalisation), and "behavioral signs and symptoms" (bruxism), with the lowest values of its categories (n=30 and n=12 respectively), moving away from the centroid.
From another perspective, we found that the women frequently showed behavioral/emotional change (38%), suicidal behaviors (17,7%), incident (5,2%), interpersonal violence (4,1%), and social situations (0,3%). Males only stand out in homicidal behaviors (0,3%). This gender variation maybe the result of the diverse management of emotional stages (Ekman, 2004). In an attempt to explain the phenomenon that the gender as a psychosocial construction will inevitably influence the expression of mental health, Canetto (1997, 1991) concluded that there are higher differences in the pathology rates for women, such as depression, generalized anxiety, panic, and phobia. In cases of men, rates are higher in alcohol disturbed, drug abuse, and anti-social disorder, which may present some relation with anti-social behavior, the use of
illicit substances, and homicide. Also, relating to the national psychiatric census in 2001, (DGS, 2004) highlighted that female are more likely to engage in depression, adaptation, personality disturbance, and neurosis (Rabasquinho & Pereira, 2007).
But, in the end, it was the symptomatology that seems to have the greatest contribution in explaining the data. The facts that cognitive and behavioral symptoms make the greatest contribution (D=0,815; D=0,707 respectively) and dimension 1 explains 40,35% of the total inertia suggest that it was more important to explain data and not so much the gender or type of occurrence. In fact, crisis intervention favours reactions at the time of the crisis rather than the event itself. The premise reveals that crisis has its origin in the interpretation of the events or situations underlying the crisis and not in the events themselves or in the facts about them (Ellis, 1962). Its basic principle is that individuals can re-establish control over crises by changing their interpretations, recognising and challenging irrational and self-destructive beliefs, and focusing on rational and robust thought elements (Dattilio & Freeman, 1994; Roberts, 2005; James & Gilliland, 2012).
There are many contributions to this study, concerning its innovative reporting to a significant sample analysis, supplying the results that allow an important preliminary knowledge about the response of the psychological intervention by telephone on pre-hospital setting. The crisis management and the psychological emergencies have been extensively studied (Lomeña, 2007; Sá, Werlang & Paranhos, 2008; Allen, Carpenter, Sheets, Miccio & Ross, 2003), although there is a lack of scientific data about the recommended action as compared to others, especially because the reality of CAPIC psychologists seems to be unique in the world. Nevertheless, this service has played a significant role in identifying the signs and symptoms which may result in a psychological crisis and the possible actions to immediately stabilize the individuals, showing even the ability to refer them for later care.
In the future, with the change in artificial intelligence logics in health care contexts, by using algorithms to support medical decision (Gyeongcheol, et al., 2019; Montani & Striani, 2018; Srividya, Mohanavalli & Bhalaji, 2018), especially in Portuguese pre-hospital medical emergency by using TETRICOSY®, we will be able to think of the creation of algorithms to preview a risk profile (based on symptomology), as a sign of alert to some intervention and referral response plans, due to the importance of the signs and symptoms known in this study.
There are still some limitations, mainly in the data register on the informatic application, which may lead to less objective data. An alteration at this level as well as the possibility to create a new variable, namely “success of intervention” is recommended to assess these results in further studies.
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APPENDIX
APPENDIX 2 – Mass, inertia, quantification and contributions of categories to dimension inertia1 Categories Mass Inertia Quantification of
categories (Centroid Coordinates) Contributions of categories Dimension Dimension 1 2 1 2 Gender Female 0,093 0,073 0,027 -0,538* 0,0001 0,163• Male 0,049 0,136 -0,053 1,007* 0,0001 0,302• Occurence type Behavioral/emotional change 0,079 0,055 -0,093 -0,294* 0,002 0,041• Homicidal behaviors 0,001 0,547 0,011 3,819* 0,0001 0,058• Suicidal behaviors 0,043 0,110 0,015 0,757* 0,0001 0,149• Incident 0,013 0,097 0,468* 0,212 0,008 0,003 Social situation 0,001 0,091 -0,250 0,889* 0,0001 0,004 Interpersonal violence 0,007 0,314 0,126 -2,125* 0,0001 0,217• Referral Without referral 0,110 0,034 0,256* -0,017 0,021• 0,0001 Social Worker 0,001 0,139 -0,849* 0,126 0,003 0,0001 Non-governmental organization 0,001 0,280 -0,825 -1,133* 0,0001 0,002 Institution 0,001 0,033 -0,835 1,064* 0,001 0,002
Primary health doctor 0,008 0,099 -0,845* 0,152 0,016• 0,001
Psychologist 0,004 0,137 -0,846* -0,113 0,007 0,0001
Psyquiatrist 0,019 0,108 -0,846* 0,087 0,039• 0,001
Another 0,001 0,186 -0,851* -0,453 0,002 0,001
Cognitive signs and symptoms
Unidentified 0,020 0,329 2,252* 0,048 0,290• 0,0001 Hallucinations 0,003 0,089 -0,303 -0,321* 0,001 0,002 Attencion shifting 0,002 0,064 -0,387* -0,057 0,001 0,0001 Increase/decrease in consciousness 0,000 0,031 -0,422* 0,207 0,0001 0,0001 Confusion 0,005 0,066 -0,380* -0,079 0,002 0,0001 Delusions 0,004 0,053 -0,336* -0,034 0,001 0,0001 Dementia 0,001 0,128 -0,341 -0,553* 0,0001 0,001
1 Asterisk (*) indicates the dimension with the most discriminatory capacity of each category. The highest contributions for each category by size are also marked with the symbol (•). Only contributions above 0.01 are indicated.
Disorientation 0,002 0,059 -0,381* -0,034 0,001 0,0001 Depersonalisation 0,000 0,319 -0,523 2,754* 0,0001 0,004
Desrealisation 0,000 0,048 -0,370 0,709* 0,0001 0,001
Speech difficulty 0,005 0,050 -0,372* 0,021 0,002 0,0001
Difficulty in identifying people 0,000 0,172 -0,410 -0,793* 0,0001 0,001 Difficulty i focusing attention 0,004 0,052 -0,403* 0,036 0,002 0,0001 Incoherent speech 0,009 0,080 -0,360* -0,203 0,003 0,002 Cognitive distortions 0,003 0,011 -0,433* 0,359 0,002 0,002 Hipervigilance 0,000 0,084 -0,273 0,860* 0,0001 0,002 Homicide ideation 0,002 0,063 -0,368* -0,071 0,001 0,0001 Suicide ideation 0,044 0,050 -0,353* 0,003 0,016• 0,0001 Intrusions 0,001 0,042 -0,268* -0,023 0,0001 0,0001 Homicide intention 0,000 0,060 -0,215 0,637* 0,0001 0,001 Suicide intention 0,026 0,051 -0,350* -0,010 0,009 0,0001 Denial 0,001 0,032 -0,354* 0,127 0,0001 0,0001 Obsessive thoughts 0,002 0,069 -0,362* -0,122 0,001 0,0001 Disturbing thoughts 0,007 0,041 -0,429* 0,145 0,004 0,001 Memory problems 0,000 0,081 -0,361 0,928* 0,0001 0,002 Another 0,000 0,093 -0,405* -0,245 0,0001 0,0001
Behavioral Signs and Symptoms
Unidentified 0,013 0,398 2,690* 0,095 0,266• 0,001 Psychomotor agitation 0,016 0,015 -0,270* 0,164 0,003 0,003 Aggressiveness/violence 0,024 0,035 -0,277* 0,028 0,005 0,0001 Antisocial 0,000 0,022 -0,484* 0,329 0,0001 0,0001 Self-mutilation 0,004 0,032 -0,274* 0,052 0,001 0,0001 Bruxism 0,000 0,551 -0,786 -3,073* 0,0001 0,002 Compulsive crying 0,018 0,023 -0,272* 0,112 0,004 0,001 Additive behavior 0,011 0,063 -0,233* -0,207 0,002 0,003 Motor discoordination 0,000 0,109 0,302 -1,062* 0,0001 0,0001 Escape 0,001 0,114 -0,354 -0,444* 0,0001 0,001 Hipokinesia 0,001 0,030 -0,363 0,575* 0,0001 0,001 Disquiet 0,010 0,094 -0,278 -0,378* 0,002 0,009 Isolation 0,004 0,085 -0,253 -0,342* 0,001 0,003 Mannerisms 0,000 0,183 -0,260 -1,018* 0,0001 0,0001 Negativism 0,002 0,048 -0,327* -0,012 0,0001 0,0001 Parakinesia 0,000 0,032 -0,201* -0,021 0,0001 0,0001 Uncooperative 0,032 0,031 -0,258* 0,041 0,006 0,0001 Food deprivation 0,002 0,061 -0,181 -0,244* 0,0001 0,001 Sleep deprivation 0,004 0,024 -0,201* 0,032 0,0001 0,0001
Rituals 0,000 0,247 0,025 -1,755* 0,0001 0,002
Tic 0,000 0,151 -0,033 1,088* 0,0001 0,0001
Another 0,000 0,009 -0,139 0,202* 0,0001 0,0001
Physiological Signs and Symptoms
Unidentified 0,043 0,172 1,225* -0,021 0,188• 0,0001 Shivering 0,000 0,159 -0,598* -0,515 0,0001 0,001 Asthenia 0,004 0,088 -0,536* -0,081 0,003 0,0001 Appetite loss 0,001 0,046 -0,518* 0,194 0,001 0,0001 Food poverty 0,001 0,086 -0,660* 0,057 0,001 0,0001 Headache 0,003 0,021 -0,525* 0,375 0,003 0,003 Muscular rigidity 0,005 0,056 -0,559* 0,170 0,004 0,001 Dyspnea 0,002 0,142 -0,541* -0,456 0,001 0,002 Fatigue 0,001 0,042 -0,632* 0,335 0,001 0,001 Hyperventilation 0,020 0,082 -0,524* -0,049 0,016 0,0001 Insomnia 0,002 0,115 -0,562* -0,244 0,002 0,001 Intoxication 0,010 0,117 -0,545* -0,270 0,008 0,004 Faintness 0,003 0,109 -0,531* -0,233 0,002 0,001 Nausea 0,002 0,034 -0,551* 0,313 0,001 0,001 Paresthesia 0,010 0,055 -0,527* 0,139 0,008 0,001
Adventitious visual impairment 0,000 0,196 -0,605 -0,764* 0,0001 0,001
Sweating 0,001 0,120 -0,530* -0,312 0,001 0,001 Tachycardia 0,004 0,081 -0,535* -0,032 0,003 0,0001 Dizziness 0,003 0,029 -0,532* 0,328 0,003 0,002 Chest pain 0,007 0,074 -0,526* 0,005 0,005 0,0001 Tremor 0,015 0,081 -0,537* -0,028 0,012• 0,0001 Vomiting 0,002 0,013 -0,495* 0,404 0,002 0,002 Xerostomy 0,001 0,001 -0,487 0,493* 0,0001 0,001 Another 0,003 0,019 -0,509* 0,377 0,002 0,003
APPENDIX 3 – Crosstabulation Cognitive Signs and Symptoms * Referral Categories Referral Total Without Referral Social Worker Non-governmental association Institution Primary health
doctor Psychologist Psychiatrist Another
Cognitive Signs and Symptoms Unidentified n 6951 0 0 0 0 0 0 0 6951 Hallucinations n 917 15 4 4 66 29 177 5 1217 Attencion shifting n 518 14 0 2 42 26 119 3 724 Increase/decrease in consciousness n 102 1 0 0 8 3 28 2 144 Confusion n 1366 27 3 0 126 80 319 12 1933 Delusions n 1168 15 4 5 81 37 230 10 1550 Dementia n 182 2 0 2 11 8 32 3 240 Disorientation n 573 8 3 2 58 23 140 6 813 Depersonalisation n 15 0 0 0 4 3 7 1 30 Desrealisation n 83 1 0 1 8 5 21 2 121 Speech difficulty n 1194 20 7 5 113 43 294 13 1689
Difficulty in identifying people n 42 0 1 0 8 3 9 2 65
Difficulty in focusing attention n 918 12 2 2 96 62 237 9 1338
Incoherent speech n 2374 37 2 6 208 104 497 25 3253 Cognitive distortions n 740 17 2 4 84 31 193 10 1081 Hipervigilance n 106 3 0 0 5 2 16 1 133 Homicide ideation n 457 4 2 0 56 18 101 8 646 Suicide ideation n 11326 167 24 55 956 404 2265 118 15315 Intrusions n 160 3 1 0 9 5 26 1 205 Homicide intention n 109 0 0 0 6 1 16 0 132 Suicide intention n 6765 95 11 19 560 238 1340 71 9099 Denial n 198 3 0 0 16 13 39 1 270 Obsessive thoughts n 436 6 2 1 35 20 86 1 587 Disturbing thoughts n 1725 36 5 9 191 87 444 22 2519 Memory problems n 99 0 0 0 4 2 18 0 123 Another n 35 0 0 0 3 1 9 0 48 Total N 38559 486 73 117 2754 1248 6663 326 50226 % within Cognitive SS 76,8% 1,0% 0,1% 0,2% 5,5% 2,5% 13,3% 0,6% 100,0% % within Referral 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% % Total 76,8% 1,0% 0,1% 0,2% 5,5% 2,5% 13,3% 0,6% 100,0%
APPENDIX 4 – Crosstabulation Behavioral Signs and Symptoms * Referral Referral Total Without Referral Social Worker Non-governmental association Institution Primary health
doctor Psychologist Psychiatrist Another
Behavioral Signs and Symptoms Unidentified n 4467 0 0 0 0 0 0 0 4467 Psychomotor agitation n 4283 47 14 16 351 156 867 39 5773 Aggressiveness/violence n 6322 88 16 22 537 241 1237 57 8520 Antisocial n 23 2 0 0 3 2 5 0 35 Self-mutilation n 932 12 0 4 73 30 173 12 1236 Bruxism n 6 0 0 0 2 0 4 0 12 Compulsive crying n 4781 75 8 19 401 168 969 52 6473 Additive behavior n 3041 43 9 6 234 110 554 28 4025 Motor discoordination n 20 0 0 0 1 1 2 0 24 Escape n 202 1 1 1 11 9 48 5 278 Hipokinesia n 179 4 0 1 14 4 32 1 235 Disquiet n 2612 39 2 9 222 93 475 32 3484 Isolation n 927 14 5 3 68 41 200 14 1272 Mannerisms n 11 0 0 0 0 0 3 0 14 Negativism n 403 5 0 2 31 22 100 3 566 Parakinesia n 45 0 0 0 5 2 9 0 61 Uncooperative n 8358 126 16 21 647 299 1650 63 11180 Food deprivation n 665 9 1 3 49 23 122 4 876 Sleep deprivation n 1121 20 1 9 98 45 188 13 1495 Rituals n 32 0 0 0 3 0 4 0 39 Tic n 14 0 0 0 0 0 4 0 18 Another n 115 1 0 1 4 2 17 3 143 Total N 38559 486 73 117 2754 1248 6663 326 50226 % within Behavioral SS 76,8% 1,0% 0,1% 0,2% 5,5% 2,5% 13,3% 0,6% 100,0% % within Referral 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% % Total 76,8% 1,0% 0,1% 0,2% 5,5% 2,5% 13,3% 0,6% 100,0%
APPENDIX 5 – Crosstabulation Physiological Signs and Symptoms * Referral Referral Total Without Referral Social Worker Non-governmental association Institution Primary health
doctor Psychologist Psychiatrist Another
Physiological Signs and Symptoms Unidentified N 15260 0 0 0 0 0 0 0 15260 Shivering N 90 5 0 0 18 7 35 3 158 Asthenia N 944 16 2 3 110 58 263 14 1410 Appetite loss N 229 3 0 0 21 15 64 4 336 Food poverty N 98 3 0 1 27 13 49 3 194 Headache N 826 19 2 5 90 28 238 4 1212 Muscular rigidity N 1102 19 4 12 151 65 373 22 1748 Dyspnea N 381 11 2 3 52 21 100 8 578 Fatigue N 150 4 0 2 29 12 65 2 264 Hyperventilation N 4758 95 12 22 557 249 1288 60 7041 Insomnia N 541 14 2 2 86 27 167 6 845 Intoxication N 2221 59 11 10 288 132 647 36 3404 Faintness N 646 16 2 6 71 31 187 7 966 Nausea N 380 5 1 2 49 26 119 6 588 Paresthesia N 2475 50 4 15 265 116 705 22 3652 Adventitious visual impairment N 57 6 2 0 5 5 23 2 100 Sweating N 211 4 1 2 21 7 65 6 317 Tachycardia N 921 17 4 4 84 51 293 18 1392 Dizziness N 823 18 4 5 97 40 221 13 1221 Chest pain N 1556 27 1 2 179 81 429 25 2300 Tremor N 3378 64 14 16 396 189 996 47 5100 Vomiting N 567 8 4 2 55 21 130 8 795 Xerostomy N 147 5 1 0 17 8 27 1 206 Another N 798 18 0 3 86 46 179 9 1139 Total N 38559 486 73 117 2754 1248 6663 326 50226 % within Physiological SS 76,8% 1,0% 0,1% 0,2% 5,5% 2,5% 13,3% 0,6% 100,0% % within Referral 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% 100,0% % Total 76,8% 1,0% 0,1% 0,2% 5,5% 2,5% 13,3% 0,6% 100,0%
APPENDIX 6 – Crosstabulation Cognitive Signs and Symptoms * Referral Refererral Total Without Referral Social
Worker NGO Institution
Primary health
doctor Psychologist Psychiatrist Another Cognitive SS Unidentified n 6951 0 0 0 0 0 0 0 6951 % within Cognitive SS 100,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 100,0% % within Referral 18,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 13,8% % Total 13,8% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 13,8% Hallucinations n 917 15 4 4 66 29 177 5 1217 % within Cognitive SS 75,3% 1,2% 0,3% 0,3% 5,4% 2,4% 14,5% 0,4% 100,0% % within Referral 2,4% 3,1% 5,5% 3,4% 2,4% 2,3% 2,7% 1,5% 2,4% % Total 1,8% 0,0% 0,0% 0,0% 0,1% 0,1% 0,4% 0,0% 2,4% Attention shifting n 518 14 0 2 42 26 119 3 724 % within Cognitive SS 71,5% 1,9% 0,0% 0,3% 5,8% 3,6% 16,4% 0,4% 100,0% % within Referral 1,3% 2,9% 0,0% 1,7% 1,5% 2,1% 1,8% 0,9% 1,4% % Total 1,0% 0,0% 0,0% 0,0% 0,1% 0,1% 0,2% 0,0% 1,4% Increase/decrease in consciousness n 102 1 0 0 8 3 28 2 144 % within Cognitive SS 70,8% 0,7% 0,0% 0,0% 5,6% 2,1% 19,4% 1,4% 100,0% % within Referral 0,3% 0,2% 0,0% 0,0% 0,3% 0,2% 0,4% 0,6% 0,3% % Total 0,2% 0,0% 0,0% 0,0% 0,0% 0,0% 0,1% 0,0% 0,3% Confusion n 1366 27 3 0 126 80 319 12 1933 % within Cognitive SS 70,7% 1,4% 0,2% 0,0% 6,5% 4,1% 16,5% 0,6% 100,0% % within Referral 3,5% 5,6% 4,1% 0,0% 4,6% 6,4% 4,8% 3,7% 3,8% % Total 2,7% 0,1% 0,0% 0,0% 0,3% 0,2% 0,6% 0,0% 3,8% Delusions n 1168 15 4 5 81 37 230 10 1550 % within Cognitive SS 75,4% 1,0% 0,3% 0,3% 5,2% 2,4% 14,8% 0,6% 100,0% % within Referral 3,0% 3,1% 5,5% 4,3% 2,9% 3,0% 3,5% 3,1% 3,1% % Total 2,3% 0,0% 0,0% 0,0% 0,2% 0,1% 0,5% 0,0% 3,1% Dementia n 182 2 0 2 11 8 32 3 240 % within Cognitive SS 75,8% 0,8% 0,0% 0,8% 4,6% 3,3% 13,3% 1,3% 100,0% % within Referral 0,5% 0,4% 0,0% 1,7% 0,4% 0,6% 0,5% 0,9% 0,5%
